Using CBT to Overcome Panic Attacks

By Roger Tilton, Ph.D.

What is Cognitive-Behavior Therapy?

Cognitive-behavior therapy has been shown in numerous studies to be the treatment of choice for anxiety disorders.  It is particularly effective in helping people overcome panic attacks.

Cognitive-behavior therapy has two components: identifying and changing the distorted thinking patterns that maintain anxiety (cognitive therapy), and desensitizing anxiety through exposure to feared situations (behavior therapy). 

The relative emphasis put on each of these depends on the nature of your problem.  For example, specific phobias, such as a fear of heights, are very effectively treated by exposure therapy alone, whereas panic disorder without agoraphobia is very successfully treated by cognitive therapy alone.  

If you have a significant amount of agoraphobic avoidance along with your panic attacks, then you will need to work both on changing your thinking and exposing yourself to the situations you fear. 

I would now like to explain some of the principles that are used to help people understand and overcome panic attacks, so that you may use them to gain mastery over your panic attacks.

What Really Are Panic Attacks?

Although panic attacks may seem as if they come out of the blue, they are actually a product of your own thinking.  When you break them down into their separate components, you can achieve mastery over them.

A panic attack is really nothing more than bodily sensations of anxiety and a catastrophic misinterpretation of those sensations as dangerous.  Your belief that you are in danger results in increased anxiety, which then leads to more sensations and more catastrophic thoughts, creating a vicious cycle between bodily sensations, distorted thoughts, and anxiety, which can rather quickly result in a panic attack.  

The real problem is actually your mistaken belief that you are in danger – not the panic itself – since panic is in fact an appropriate emotional reaction when you are convinced that you may be in danger. However, your belief is untrue, and when you understand this on a deeper level, you will master your panic.

What Are The Most Common Beliefs That Cause Panic Attacks?

People who have panic attacks are remarkably similar in the specific catastrophic thoughts they have.  The most common of these are: 

∙       You misinterpret rapid heartbeat as meaning that you might have a heart attack or heart failure.

∙       You misinterpret tightness in your chest or throat or rapid breathing as meaning that you might choke and be unable to breathe.

∙        You misinterpret lightheadedness as meaning that you are on the verge of fainting.

∙        You misinterpret harmless feelings of depersonalization or unreality as meaning that you are about to go crazy and wind up in a mental hospital.

∙        You mistakenly believe that when you panic, you might lose control and do something rash or impulsive, such as losing control of your car, running from your car in traffic, or flagrantly embarrassing yourself.

∙        Even though what you fear never happens, you mistakenly tell yourself, “This time is different”.  

Good News:  None Of These Things Are Going To Happen.

∙        Rapid heartbeat and “respiratory” sensations are merely normal sensations of physiological arousal, mobilizing you for fight or flight. 

∙        Fainting is caused by a sudden drop in blood pressure, but when you become anxious, your blood pressure goes up, making fainting almost an impossibility. 

∙         People with anxiety disorders never go crazy.

∙        People experiencing a panic attack never lose control and, in fact, are actually more in control than they need to be.

∙        This time is not different nor will the time after this be different.

Identifying Sensations And Thoughts

The first step in overcoming panic attacks is to identify the bodily sensations you are experiencing and the catastrophic thoughts you are having about these sensations.   It is important that you separate your thoughts and sensations.  For example, “I feel like I’m going to faint” is actually a sensation of lightheadedness and a thought or belief that you are about to faint.  “I feel like I’m choking” is a sensation of tightness in your throat and a thought or belief that you will choke and not get enough air. 

Identify and separate your sensations and thoughts by writing them down in two columns: one titled “Sensation” and the other titled “Thought”.  Keep in mind that sensations do not cause anxiety. It is your beliefs about sensations that cause anxiety.  

Coming Up With An Alternative Explanation

Once you are able to separate and clearly identify your sensations and thoughts, the next step is to write down an alternative and more objective explanation for the sensation.  After writing down the sensation and the catastrophic thought, add a third column titled “Alternative Explanation.”   If you have more than one sensation that you fear, do this for each sensation.

Looking At The Evidence

As you do this, ask yourself which explanation has been more accurate in your experience so far – your catastrophic thought or your alternative explanation?  What, if any, evidence supports your catastrophic thought and what evidence does not support it?  Which of the two appears to be the more reasonable explanation?

Becoming More Objective At Times Of Greatest Anxiety

When you are very anxious, the tendency is to believe your catastrophic thoughts of danger, so you need to work at becoming increasingly more objective about your thinking at times of greatest anxiety. It is important at these times to write down your sensations, thoughts, and alternative explanations and then look as objectively as possible at the evidence.

The very act of writing things down during a panic attack can itself help you to assume a more objective perspective.  At first, you will find that you are able to accept your rational alternative explanation when you are not anxious, but that it is harder to do so when you are highly anxious.  This is understandable, but as you work towards becoming more objective about your thinking during times of high anxiety and panic, you will find that your degree of belief in your irrational thoughts will begin to diminish.

As your degree of belief continues to diminish, you will see that your level of anxiety decreases along with it.  When your degree of belief approaches zero, your anxiety will be gone.

As you go through this process, you will see how very close the relationship is between your thinking and how you feel. The key to mastering panic attacks is to fully realize – while you are having a panic attack – that your catastrophic thoughts are merely untrue thoughts that you need not accept.  When you no longer believe these thoughts, there is nothing left to feel anxious about!  At that point, you will fully understand that a panic attack is just a false alarm that you can turn off at will.

A Case Example

Sam provides a good example of how panic attacks are overcome in this way.  For 15 years, Sam had feared driving on the freeway and was only able to drive for 5 miles, in the right lane.

It turned out that what Sam really feared was that he might have a panic attack and lose control of his car.  Even though he had many times experienced panic attacks on the freeway without this ever occurring, he still believed that it might yet happen.

I explained to Sam that panic attacks never lead to a loss of control.  He told me that no one had ever told him this, and by the end of the session he said that he believed me.  

The next time he drove on the freeway, he became anxious and again had the thought that he might lose control of his car.  However, while he still believed this was possible, his degree of belief in the chance of this happening had dropped from about 95% to 70%, which resulted in a noticeable decrease in his anxiety.

During the next week, when he drove on the freeway, his degree of belief dropped to 50%, with the intensity of his anxiety decreasing further.  The following week, his degree of belief was at 25%, with only mild anxiety.  

After 6 weekly therapy sessions, Sam no longer believed that anxiety could cause him to lose control of his car, and he no longer feared having a panic attack, which he now realized was harmless.  At this point, he was able to drive alone on the freeway on a 120-mile round trip without anxiety.  He even drove a good part of the way in the fast lane – something he had completely avoided for the past 15 years.

Some Important Points To Remember

∙        A thought in itself cannot make you anxious.  You have to believe the thought, and you have the power to choose whether or not to believe it.

∙        In order to have a panic attack, you have to tell yourself something that is not true.  The truth is that panic attacks are not dangerous.

∙        When you have a panic attack, you temporarily lose your perspective and don’t see the truth.  When you regain your perspective, your panic attack will end abruptly.

∙        What people really fear is what they imagine a panic attack will lead to.  However, the only thing a panic attack ever leads to is the panic attack ending.

∙        Look at a panic attack as an opportunity to master panic attacks. 

∙        Taking an objective perspective and reminding yourself of the truth at times of high anxiety is the key to overcoming panic attacks.

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